The document is a confidential questionnaire from the International Organization for Migration (IOM) for their minimum medical review. It requests staff to provide information about their health status and history to evaluate fitness for duty and availability of healthcare at their duty station. Staff must complete and return the form within 3 days to the applicable IOM medical officer. The questionnaire asks about hospitalizations, medications, planned medical care, pregnancy, limitations, vaccinations, and consent to release medical information.
The document is a confidential questionnaire from the International Organization for Migration (IOM) for their minimum medical review. It requests staff to provide information about their health status and history to evaluate fitness for duty and availability of healthcare at their duty station. Staff must complete and return the form within 3 days to the applicable IOM medical officer. The questionnaire asks about hospitalizations, medications, planned medical care, pregnancy, limitations, vaccinations, and consent to release medical information.
The document is a confidential questionnaire from the International Organization for Migration (IOM) for their minimum medical review. It requests staff to provide information about their health status and history to evaluate fitness for duty and availability of healthcare at their duty station. Staff must complete and return the form within 3 days to the applicable IOM medical officer. The questionnaire asks about hospitalizations, medications, planned medical care, pregnancy, limitations, vaccinations, and consent to release medical information.
The document is a confidential questionnaire from the International Organization for Migration (IOM) for their minimum medical review. It requests staff to provide information about their health status and history to evaluate fitness for duty and availability of healthcare at their duty station. Staff must complete and return the form within 3 days to the applicable IOM medical officer. The questionnaire asks about hospitalizations, medications, planned medical care, pregnancy, limitations, vaccinations, and consent to release medical information.
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CONFIDENTIAL
IOM MINIMUM MEDICAL REVIEW
QUESTIONNAIRE
Explanatory note:
The purpose of this questionnaire is to evaluate the current health status in conjunction with the availability of health care services in their proposed duty station. The IOM Medical Officer of the Occupational Health Unit (OHU) determines whether any further investigations or information is deemed to be necessary.
Please electronically complete and return this questionnaire as soon as possible (preferably within 3 days) byemail to the IOM Medical Officer of the applicable unitof the Occupational Health Unit (OHU) in:
PANAMA: for staffin Africa or in the Americas
Switzerland -GENEVA: for staff in Headquarters Philippines -MANILA: for staff in all other locations
Family Name (in block capitals): HARUN Duty station: IOM Cotabato Sub Office
Given names:AL-WAHAB
Date of birth (D/M/Y): 08/08/1982 Gender:Female __Male __Other*__
*difference of sexual development (DSD, intersex)
Nationality: Filipino Home address: Cagayan De Oro City
E-mail: Telephone numbers (incl. country code): none
OHU_MMRQ_2019 (EN)
1 Name, full address, telephone number and email of your doctor:
Family doctor: None
Specialist health professional if any (indicate the type of specialty) None
1. Have you been admitted to the hospital for at least 2 consecutive days in the last 5 years, or have you been absent from work for more than 30 days in the last 12 months?
Yes____ No____If “yes please indicate the medical reason / diagnosis
2. Are you regularly taking any prescribed medication? Do you have any allergies to medication?
Yes____ No____If “yes” please provide details(please include name/or generic name of medication, dose and frequency)
3. Do you have any condition which will need medical, surgical or psychological intervention or treatment within the next 12 months or an ongoing treatment?
Yes____ No____If “yes please provide detail
4. Are you currently pregnant?
Yes____ No____ If “yes” please state the expected date of delivery (D/M/Y):
5. Do you have any physical or mental health conditions which could make it difficult for you to live and work in, or travel to, a remote area with limited access to health care facilities?
Yes____ No____If “yes” please provide details and medical certificate
6. Have you ever suffered from a physical or psychological condition which has been recognized as caused by previous work or internship?
Yes____ No____If “yes please provide details
7. Do you, or will you need any workplace accommodations for medical conditions, and/or disability? (For example do you have travel limitations, or need a special desk, etc.)
Yes____ No____If “yes please provide details
8. Are you aware of any other factors which could affect your health or your ability to perform your duties (such as physical symptoms, lifestyle habits or family circumstances)
OHU_MMRQ_2019 (EN)
2 Yes____ No____If “yes please provide details
9. Have you had any of the following symptoms in the past 6 months? None
Underline the symptoms concerned and give details: Coughing or spitting blood, breathing difficulties, blood in your stools, blood in your urine, chest pain, breathing difficulties, abdominal pain, back pain, fainting, loss of consciousness, seizure, depression, panic attacks, vertigo, involuntary loss of weight (over3kg), heartpalpitations,unexplained chronic fatigue, transient palsy or loss of vision.
Please provide a copy of your full vaccination record: None
Declaration - Please read, sign and either check ACCEPT or DECLINE the declaration
I hereby declare that my answers to all questions are true and complete to the best of my knowledge. I also hereby authorize the reviewing Medical Officer to communicate with my treating physician, or mental health professional, and I simultaneously give consent to my treating practitioner(s) to release the necessary medical information in order to verify my state of health in relation to fitness for work.
I understand that failure to disclose a known physical and psychological condition, including conditions under investigation, may result in future denial of benefits, termination or dismissal.
You must check one box:I ACCEPT ____ I DECLINE ____
Date: December 11, 2020 Staff’s signature:
For administrative internal use only:
Date:
Fitness classification 1A____ 1B____ 2 ____
Further information neededor referral to SW advised:
